The impact of WASH on maternal & newborn health: What do ... · Unacceptable ANC, delivery & PNC services Infections: enteric, parasitic, respiratory Unacceptable child health services

The impact of WASH on maternal & newborn health:

What do we know?

Joanna Esteves MillsCEO SHARE Consortium

London School of Hygiene & Tropical Medicine

Is Sanitation correlated with Maternal Mortality? Yes.... Water is Too

Source: Gapminder.org

What about Sanitation and Neonatal Mortality? Yes.... Water Too

Source: Gapminder.org

Conceptual framework

Oona Campbell, Lenka Benova, Oliver Cumming, Giorgia Gon, Kaosar Afsana


Three lenses:

2. Gendered inequalities

1. WASH transmission

3. Life-course approach

1. In the water 2. Behaviour & location



WASH transmission

Water-borne Infections – via bacterial, parasitic and viral oral-faecal infections; Inorganic chemical compounds – natural contaminants

Water-washedInsufficient water for personal/domestic/institutional hygiene; Poor hygiene and faeces disposal

Water-relatedVia insects near water

Water-basedInfections - via aquatic vector


WASH transmission

Distance water sources or lack of water when needed Physical burden of carrying water, time and financial costs, drudgery

Perception of water and sanitation availability; stigma or feararound use of sanitation facilitiesReal or perceived availability of water or sanitation

Water/sanitation in risky or isolated locationsPests and perverts

1. In the water

Ingestion, inhalation or contact with 'contaminated' water

A. Water-borne chemical compounds ingested or

in contact with skin

Natural contamin

ants

e.g. arsenic,

salt, fluoride

Arsenic-osis

Indust-rial

contaminants

e.g.

lead, nitrates

Blue baby

Delib-erate

additive e.g.

fluorine, chlorine or its by-products

Spont-aneous

abortion

B. Water-system related

infection

Via aerosols

from poorly manag-

edcooling systems

Legion-ellosis

C. Water -based

infection

Via aquatic vector

e.g.

fish & tape-

worm, shellfish & flukes, snails & schisto-somes

Schisto-somiasis

D. Water-borne

infection

Via bacterial parasitic,

& viral oral-

faecal infection

s e.g. cholera, listeria,

hepatitis E

Hepatitis E

2. Behaviours related to WASH

Availability/location of water & sanitation, logistics of handling them, or stigma of biological processes

E. Water-washed Insufficient water for personal/domestic/

institutional hygiene; Poor

hygiene & faeces disposal

Via enteric

infection e.g

diarrhea& gastro-enteritis, spread

by fingers, food,

fomites, field

crops, fluids, or

flies

Hook-worm

Other infection

(eye, ear, skin, lice-

borne, respira-

tory)

e.g.

Tracho-ma

scabieslassafever

Influenza

F. Water-related insect-vector borne

infection

Via insects

near water

e.g.

black flies &

onchocerchiasis, tsetse flies &

trypanosomes

Malaria

G. Water sources

distant or absent

Physical burden of carrying water, time &

financial costs,

drudgery

Uterine prolapse

H. Water/ sanitation in risky or

isolated locations

Pests (insect &

snake bites)

and perverts (harass-ment &

violence)

Rape

I. Perception of water and sanitation availability; stigma

or fear around use of sanitation facilities

Real/ per-

ceivedrisk,

stigma, damage to self-

esteem, or

disgust surround

-ingdefeca-

tion, urina-tion or

menstruation

Mental distress

Real or perceived avail-

ability of water or

sani-tation

Lack of use of health

services


Gender inequalities perspective

Diseases or conditions that are:

• unique to women or some subgroup of women

• more prevalent

• more serious

• for which the risk factors are different

• for which the interventions are different

(National Institutes of Health (1991))

For example: water-borne infectionsCholera versus Hepatitis E.

Infections: cord, skin & eye

Opportunity costs

Obstructed labour

Maternal DeathStunting

Cognitive impairment

School absenteeism/dropout

Prolapse

Spinal compression

Caloric expenditure

C-section

Spontaneous abortion

UTI

Repeated pregnancy

Unacceptable ANC, delivery & PNC services

Infections: enteric, parasitic, respiratory

Unacceptable child health services

Anaemia, rheumatic disease

Early marriage

Early childbearing

Pelvic inflammatory disease

InfertilityStigma

Low birth weightMorbidity

Poor mental health

Orphans

Harassment, rape

UTI

Unacceptable FP services

Stillbirth

AnaemiaCardiac disease

Unacceptable schools

Short adult

Conceptual frameworkLife course perspective


Opportunity costs

Obstructed labour




Prolapse

Spinal compression

Caloric expenditure

C-section


UTI

Repeated pregnancy





Early marriage

Early childbearing


InfertilityStigma


Poor mental health

Orphans

Harassment, rape

UTI


Stillbirth



For example: infections

Short adult


Opportunity costs

Obstructed labour




Prolapse

Spinal compression

Caloric expenditure

C-section


UTI

Repeated pregnancy





Early marriage

Early childbearing


InfertilityStigma


Poor mental health

Orphans

Harassment, rape

UTI


Stillbirth



Infections Stunting

Short adult


Opportunity costs

Obstructed labour




Prolapse

Spinal compression

Caloric expenditure

C-section


UTI

Repeated pregnancy





Early marriage

Early childbearing


InfertilityStigma


Poor mental health

Orphans

Harassment, rape

UTI


Stillbirth



Short adult

Infections Stunting


Opportunity costs

Obstructed labour




Prolapse

Spinal compression

Caloric expenditure

C-section


UTI

Repeated pregnancy





Early marriage

Early childbearing


InfertilityStigma


Poor mental health

Orphans

Harassment, rape

UTI


Stillbirth



Infections Stunting Obstructed Labour

Short adult


Opportunity costs

Obstructed labour




Prolapse

Spinal compression

Caloric expenditure

C-section


UTI

Repeated pregnancy





Early marriage

Early childbearing


InfertilityStigma


Poor mental health

Orphans

Harassment, rape

UTI


Stillbirth



Infections Stunting Obstructed Labour C-section or Maternal Death or Stillbirth

Short adultWe found 67 potential biological/chemical linkages and 10 potential behavioural linkages

Insufficient evidence of impact

Insufficient evidence

Systematic reviews, secondary analyses & new data collection tools and analyses needed!

Supported by:

through the SHARE Research Consortium

The SHARE Research Consortium

generates new findings and

synthesis of existing knowledge on

sanitation and hygiene in order to

improved policy and practice.

shareresearch.org

Thank you

Clean birthing practices: a

mixed-methods observational

study in health care facilities in

Nigeria

Helen Buxton1; Erin Flynn1; Dr Olutunde Yinka2 Joanna EstevesMills1; Tess Shiras1; Stephen Sara2 Oliver Cumming1; Robert Dreibelbis1

1. London School of Hygiene and Tropical Medicine; 2. Maternal and Child Survival Program

Hygiene During Labor and Delivery

• Infection during labor

and delivery

• 10% of all maternal

deaths

• 15% of neonatal deaths

• Easily prevented

through improved

hygiene and infection

prevention and control

protocol

• Improvements proven

difficult

• Organizational barriers

• Environmental barriers

• Models based on

knowledge and

education

Understanding hygiene practices during labor

and delivery

• Childbirth is complex, • Multiple, embedded procedures

• Long duration with intermittent provider interaction

• Assessments tend to focus on binary relationships between hand hygiene practices and specific events• HWWS and glove use prior to vaginal examinations

• Need better methodologies that capture dynamic nature of risk

23

Background: Nigeria

Neonatal mortality rate:

• 34/1,0001

• SDG target: 12/1,000

Maternal mortality:

• 560/100,0002

• SDG target: 70/100,000

1. Liu (2015); 2. World Bank (2015)

Photo credit: Lucia Zoro Save the children

24

MCSP Infection Prevention Activities

Maternal and Newborn Interventions

WASH activity description

Materials/ Supplies

Provided IPC supplies/materials to delivery rooms and for general HCF use (hw stations, soap, personal protective supplies, disinfectant, veronica buckets)

Promotion Promoting chlorhexidine use and compliance with the 6 clean birth practices among health care providers

Promotion of hand hygiene and clean cord care among mothers and other caregivers (indirectly through health care providers)

Training Training of health care workers on the 6 clean birth practicesTraining of health care workers on providing hand hygiene and cord care promotion to mothers and other caregivers during discharge

Pre-service training

Training of trainers to deliver service training on hand hygiene, the 6 clean birth practices, or IPC

25

Observations

Methods

• 30 structured observations of birth and post-natal care• 2 primary HCF

• 2 secondary HCF

• 2 tertiary hospitals

• Focus on hand and hygiene action

• Capture qualitative contextual information; follow-up qualitative

26

Birth

•6 hours

Post-natal care

•8 hours

Hand hygiene during labour and delivery: WHO integrated management of pregnancy and childbirth guidelines 2015

Before

14. WHO (2015)

After

Contact with mother Contact with new-born Any treatment procedure

Contact with blood, other bodily fluid Disposing of infectious waste Changing soiled bedsheets Changing gloves

27

Patient protection HCW protection

Vaginal examination Delivery Cord cutting Repair of tears Blood drawing Manual removal of the placenta

Handling and cleaning equipment Handling waste Cleaning blood and bodily fluids

WASH and Hygiene Infrastructure / Supplies

Indicator Number of facilities

Facility-level

- Have piped water source 3 / 6

- Experience water shortages 4 / 6

Delivery Unit

- Functioning handwashing station 6 / 6

- Functioning tap 4 / 6

- Veronica bucket 2 / 6

- Disposable towels 0 / 6

Post-natal care

- Handwashing facilities 2 / 6

- Easily cleaned, waterproof mattress covers 5 / 6

- Visibly clean bedsheets 3 / 628

WASH and Hygiene Infrastructure / Supplies

Indicator Number of facilities

Facility-level

- Have piped water source 3 / 6

- Experience water shortages 4 / 6

Delivery Unit

- Functioning handwashing station 6 / 6

- Functioning tap 4 / 6

- Veronica bucket 2 / 6

- Disposable towels 0 / 6

Post-natal care

- Handwashing facilities 2 / 6

- Easily cleaned, waterproof mattress covers 5 / 6

- Visibly clean bedsheets 3 / 629

Hygiene Scoring for HCF Workers

Proper hygiene protocol: Hands washed with soap, gloves worn

Time

30



Time

Basic hand hygiene: Hands washed with soap, no gloves

31



Hands gloved, no HWWS

Time


32


Hygiene Risk: Hands or gloves come into contact with potential contamination



Time


33


Hygiene Risk: Hands or gloves come into contact with potential contamination



Time


34

Low Risk Events:• Contact with mothers skin (intact)• Contact with clean surfaces near mother• Contact with newborn’s skin (intact)

High Risk Events• Contact with feces• Contact with placenta• Contact with another patient• Contact with medical waste


Hygiene Risk (low): Hands or gloves come into contact with skin, clean surfaces



Time

Hygiene Risk (high): Hands or glove contact with waste, blood, other patient


35


Hygiene Risk (low)

Proper hygiene protocol

Gloves, no HWWS

Time

Hygiene Risk (high)

Basic Hand Hygiene

36


Time

37


Time

38

Procedures requiring aseptic technique• Vaginal examinations• Insertion of urine catheter• Insertion of IV cannula• Artificial rupture of membranes• Manual removal of placenta, clots• Suturing of the perineum• Cord cutting• Cord contact

Hygiene during labour and delivery

40

All procedures

requiring aseptic

technique

n %

Proper hygiene protocol 7 3%

HWWS 7 3%

Hands gloved, not washed 60 27%

Hygiene risk (Low) 116 45%

Hygiene risk (High) 56 21%

Total 256

Key Findings

Conveniently placed handwashing infrastructure with both water and soap is necessary but not sufficient to ensure hand hygiene compliance

Glove use being used as a substitute for HWWS

Knowledge around hygiene protocols is high, training only reinforcing knowledge

• Accountability and supervision

• Motivation and ability, particularly during shifts with fewer staff

Visitors and auxiliary staff play a large role in maternal and newborn care

• Largely absent from most IPC training and interventions

• When included, focus on a small set of specific behaviours (ie: cleaning surfaces)

42

Next Steps

MCSP Nigeria developing new training

programs, focusing on supervisory support and

critical moments for handwashing

Integrate findings into larger literature review,

facility observations, and global key informants

43

For more information, please visit

www.mcsprogram.org

This presentation was made possible by the generous support of the American people through the

United States Agency for International Development (USAID), under the terms of the Cooperative

Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not

necessarily reflect the views of USAID or the United States Government.

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The impact of WASH on maternal & newborn health: What do ... · Unacceptable ANC, delivery & PNC services Infections: enteric, parasitic, respiratory Unacceptable child health services